Typical symptoms of UC are diarrhoea, bloody stool, and abdominal pain. Others include urgency or tenesmus, malaise, weight loss, and fever – depending on the extent and severity of the disease.^1,2

Complications of UC include leak from anastomosis, pelvic abscess, enterocutaneous fistulas, pouch prolapse, pouchitis, incontinence, sexual dysfunction, toxic megacolon and colon/rectal cancer.¹

Challenges in the management of UC

Some of the challenges in the treatment of UC include:^3,4,5,6,7

1. Individual variability: Patients with UC respond differently to treatment. It is therefore challenging to determine the most effective treatment approach for each patient.⁴
2. Disease severity: Patients can have variable disease courses. Treatment approaches depend on disease activity (mild-to-moderate and moderate-to-severe active disease) and the overall severity. It is also important to consider disease extent when planning treatment, as this may affect the optimal route of drug administration.^3,5
3. Adherence: Studies show that non-adherence affects 40% to 60% of patients, which has a substantial impact on the disease course. Non-adherence negatively impacts patient outcomes and increases the risk of flares or hospitalisation.⁶
4. Comorbid psychiatric disorders: Patients with UC are at high risk of comorbid psychiatric disorders because of the chronicity of the disease, the distressing nature of symptoms, as well as physical weakness. A recent study showed 7% of patients with UC suffer from anxiety and 58.6% from depression. Management of these comorbidities should be part of the treatment plan.

Goals of treatment

According to the authors of the 2022 ECCO guideline, the ultimate goal of treatment is to maintain health-related quality of life and avoid disability.  To achieve this, it is important to not only provide rapid relief of clinical symptoms but also achieve endoscopic healing where possible, as this is associated with improved long-term outcomes.³

Conventional therapy includes 5-aminosalicylates (5-ASA), corticosteroids, and thiopurine immunomodulators. Newer treatment options include biologics and biosimilars as well as other novel targeted small molecules.³

Pharmacotherapy for mild-to-moderate active UC

According to the American Gastroenterology Association, the majority of patients have mild-to-moderate disease, which is characterised by periods of activity or remission. For these patients, the new ECCO guideline recommends:^3,8

• 5-ASA at a dose of ≥2 g/day to induce remission
• Topical (rectal) 5-ASA at a dose of ≥1g/day for the induction of remission in patients with active distal colitis
• Topical steroids for the induction of remission in patients with active distal colitis
• Topical 5-ASA for the maintenance of remission in patients with distal UC
• Monotherapy with thiopurines for the maintenance of remission in patients with steroid-dependent UC or who are intolerant to 5-ASA
• Topical 5-ASAs over topical (rectal) steroids for induction of remission in patients with active distal UC
• Oral 5-ASA (≥2g/day) combined with topical (rectal) 5-ASA over oral 5-ASA monotherapy for induction of remission in adult patients with active UC of at least rectosigmoid extent
• Colonic-release corticosteroids for induction of remission in patients with active mild-to-moderate UC
• Topical 5-ASA for the maintenance of remission in patients with distal UC
• Against the use of thiopurines as monotherapy for the induction of remission in patients with active UC.

Pharmacotherapy for moderate-to-severe active UC 

ECCO recommends (the below are all strong recommendations, only agents available in South Africa are included):³

• Oral prednisolone for induction of remission in non-hospitalised patients
• Treatment with anti-tumour necrosis factor (TNF) agents (eg infliximab, adalimumab) to induce remission in patients who have inadequate response or intolerance to conventional therapy
• Anti-TNF agents for the maintenance of remission in patients with UC who responded to induction therapy with the same drug. In UC patients who have lost response to an anti-TNF agent, there is currently insufficient evidence to recommend for, or against the use of therapeutic drug monitoring to improve clinical outcomes.

REFERENCES

1. Lynch WD, Hsu R. Ulcerative Colitis. [Updated 2022 Jun 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. https://www.ncbi.nlm.nih.gov/books/NBK459282/
2. Fukuda T, Naganuma M, Kanai T. Current new challenges in the management of ulcerative colitis. Intest Res, 2019.
3. Raine T, Bonovas S, Burisch J, et al. ECCO Guidelines on Therapeutics in Ulcerative Colitis: Medical Treatment. Journal of Crohn’s and Colitis, 2022.
4. Fiocchi C. Inflammatory Bowel Disease: Complexity and Variability Need Integration. Front Med, 2018.
5. Pabla BS, Schwartz DA. Assessing Severity of Disease in Patients with Ulcerative Colitis. Gastroenterol Clin North Am, 2020.
6. Kim ES, Kang B. Assessment of Medication Adherence and Pharmacist Intervention Are Important for the Care of Patients with Inflammatory Bowel Disease. Gut Liver, 2022.
7. Sneineh AA, Ali SH, Al-Masri A, et al. Prevalence of anxiety and depressive symptoms in ulcerative colitis patients in Jordan and its relationship to patient-reported disease activity. Nature Scientific Reports, 2022.
8. New guideline provides recommendations for the treatment of mild-to-moderate ulcerative colitis (2019). https://gastro.org/press-releases/new-guideline-provides-recommendations-for-the-treatment-of-mild-to-moderate-ulcerative-colitis/